December 06, 2010

The father of modern geriatric medicine, Robert Butler, died last summer at the age of 83. His contributions to the study of aging and to the care of older people were prodigious: he was the founding director of the National Institute on Aging, the division of the National Institutes of Health devoted exclusively to the elderly; he persuaded Mount Sinai School of Medicine to establish the first ever Department of Geriatrics-and was promptly appointed its first chairman; his book, Why Survive: Being Old in America, published in 1975, made the case that America was "ageist" and argued forcefully that views of older people as feeble and "senile" reflected prejudice and ignorance, analogous to "racism."

Less well-known is Butler's endorsement of the idea of a "life review." Older individuals frequently look back on their lives, trying to create a coherent narrative that helps give meaning to their lives. Butler coined the term "life review" for this process and, far from mocking it as a sign of incipient dementia, as was the fashion in the 1950s, he encouraged the practice, suggesting it gave older people the opportunity to find what Erik Erikson called "ego integrity" in the final stage of life.

American medicine, by contrast, has focused on finding a quick fix to the problems of aging. Vitamin E, an anti-oxidant, was heralded as a miracle drug, until it turned out that instead of preventing heart disease and cancer, it had no effect in preventing either one and seemed to increase the risk of heart failure. Estrogen for women met a similar fate: touted as the fountain of youth and alleged to prevent such age-associated ailments as dementia and coronary artery disease, it was found to be useless in protecting against dementia and to increase the rate of heart disease. Vitamin D, the most recent candidate for anti-aging potion, just this month met the same fate. The Institute of Medicine concluded that vitamin D had not been shown to boost immunity, to prevent cancer, or to stave off diabetes.
The search for a magic bullet to prevent aging has led us to neglect the quality of life for those who are already old, and who may be frail or demented.

One strategy we already have for improving life satisfaction in old age is life review. A series of small studies this past year have confirmed the utility of life review for psychological well-being. One study of reminiscence therapy in Taiwan nursing homes found less loneliness, less depression, and greater psychological well-being in the experimental group. Similar results emerged from a randomized study conducted in ten Danish nursing homes. A Dutch randomized trial conducted in the community found that enrollment in a life review course called "Looking for Meaning" reduced depressive symptoms, a result that persisted at six months.

Unlike medications, life review has virtually no side effects. But unlike new drugs covered by patents, it will not enrich anybody and has no powerful corporate sponsors (Venlafaxine, an antidepressant, cost $70 for a one-month supply, according to Drugstore.com, and Quetiapine, an antipsychotic commonly used for symptoms such as agitation, costs $90 for a one-month supply).

I recently engaged in a limited form of life review with my parents, who are now 85 and 86. I interviewed them at length about their experiences during their first 25 years. Both were born Jewish in Germany, my mother in the port city of Stettin (now Szczecin, Poland) and my father in the small East Prussian town of Osterode (now Ostroda, also in Poland). In January, 1939, they both left Germany forever on a children's transport to Belgium. When Germany invaded Belgium in May, 1940, they escaped by train to the south of France as part of a group of 100 refugee children. There they remained, in a children's colony supported by the Swiss Red Cross, until they were threatened with deportation to Nazi death camps and fled, in 2 separate expeditions, over the border to Switzerland. My interviews focused on their early lives in Germany and their experiences as refugees, first in Belgium, then in France, and next in Switzerland. After the war, refused residency by the Swiss, they immigrated: my father to Brazil and from there to the U.S., and my mother directly to the U.S.

The process of telling their story, while sometimes painful, was clearly valuable to my parents. They found it helped them make sense of their lives to think about how their early experiences affected them as American citizens and as parents. They felt there were lessons to be learned-lessons about countries' responsibilities to refugees and about what it means to act humanely-which they were eager to communicate and hence were gratified to see their story made public in my recently released book, Once They Had a Country: Two Teenage Refugees in the Second World War.

So as we salute Robert Butler for his many invaluable contributions to geriatrics, let us not forget the humble life review.